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A Trip Down Memory Lane

The year was 1980, and the place was Augusta, Georgia. It was 35 years ago this May that I learned all my doctoral requirements had been satisfied, and I was cleared to graduate from the Medical College of Georgia School of Dentistry. A few classmates thought our Dean was bluffing about holding them up because of unsatisfied gold filling requirements. Those guys had to stay during the summer and do nothing but pure condensed gold fillings. But like me, about 60 of my 65 classmates were deemed ready to take the Georgia State Dental Board for which we were all preparing in June.

Graduation was a big deal at Medical College of Georgia, as it is in most college towns. I think MCG rented the Augusta Civic Auditorium to have enough space. First, there were some Associate degrees awarded to the radiation techs, dental lab techs, and physical therapy assistants. The vast majority of degrees awarded were Bachelor’s, awarded to nurses, physical therapists, medical lab techs, and dental hygienists. Finally, the PhD, MD, and DMD degrees were awarded to the researchers, physicians, and dentists. Each of us had to walk on stage, shake the President’s hand, and receive our sheepskin. I was quite a prankster at the time, and searched high and low for a hand buzzer to use on the college President. Guess it was fortunate I never found one! Degrees in hand, we medical and dental graduates were ready to take the Georgia State Boards. Without a state license, it was impossible to practice anywhere and actually earn a living!

Few patients realize how difficult the various state dental boards were at that time. In Georgia, applicants had to do resin, amalgam, and cast gold fillings on live patients. We were tested on a lot more procedures in the lab, and had to take a written test on Georgia practice law. My patients faithfully showed up for the Boards, but not everyone’s patients did. A patient not showing for this important appointment may mean the young dentist could not practice for another six months, when the Board was given again. It was not uncommon for us poor dental students to have to pay patients bribes in order to show up for this grueling test.

There were several Board examiners on the clinic floor those two days, and I was lucky enough to get an amiable one. He was building a swimming pool behind his house, and we bantered back and forth about that subject during my work on patients. It kept him in good humor, and our conversation relieved the incredible stress on me that this important exam imparted.

Casting my gold filling in the lab went flawlessly, and all the examiners seemed to like my work. Soon a notification came in the mail that I had passed! I was legal to practice, at least in Georgia. Later, while in the Navy, I took North Carolina’s and Tennessee’s Board for good measure. (I never practiced in either of those states, but still keep my license active in North Carolina, because it was such a hard exam!)

People don’t remember how tough the early 1980s were. We had double digit inflation AND unemployment. Interest rates were approaching 20%! America was in a funk with hostages in Iran. An actor named Ronald Reagan had yet to be elected president. The future looked pretty dim for us new graduates. Hardly any older dentists needed younger associates. The few ones that did, sure didn’t want left-handed graduates like me.

The harsh reality was that almost no place in Georgia could support additional dentists in 1980. Only one county in South Georgia was actually recruiting for a second dentist to serve its population of 10,000 people. With demographics like that, I thought, what could go wrong? (Plenty that I did not realize at the time.) I spent my life savings on a piece of land that was a cantaloupe patch. I still remember going to the county courthouse and registering my new dental license by signature in a huge bound book over 100 years old. Two local banks lent me a good amount of money at high interest to open a new dental practice in the small rural town that was the county seat. Just my luck that year the county had its worst drought in 75 years, and crop failures went with it. 1981 was not much better. After my fledgling business folded, I spent the next seven years of my life trying to get the guts to buy my second practice. That initial business failure was quite the personal defeat for me. But all one can do is keep trying, and eventually success will come.

Well, here it is 35 years after graduation. I have actually treated patients for 38 years of my life. You see, Medical College of Georgia’s Dental School was quite progressive for the time, having us starting to treat patients in the spring of our freshman year. So by 2017, I can claim to have healed fellow humans for 40 years!

My professional life has been quite an adventure, meeting dentists at conferences all over the world, as well as treating indigent patients in Lebanon and Peru. I will have to admit these last years practicing in the beautiful Henry Building sure beat my early days in South Georgia, the Navy, and a couple of Atlanta clinics that will remain nameless.

God willing, I intend to practice for at least 50 years like three dentist-heroes of mine. My wife may not let all those years be full time practice. It is rewarding to relieve human suffering, and put diseased tissues back into healthy condition. Even after thirty five years, having the legal privilege to cut and repair human tissue is an awesome responsibility. I have helped a lot of patients all these years. If you are reading this, you are probably one of them!

There are a number of clear orthodontic aligner systems on the market. The name that patients know best is Invisalign®, which is a product of Align Technologies. Patients always ask me for Invisalign, and I tell them I don’t use that brand of aligners. Why not?

Invisalign costs a lot more than other aligner systems. Therefore, patients must pay a lot more to have this particular brand of aligners.

Align Technologies wants dentists to take a weekend course and be “licensed” to use Invisalign. It is ridiculous for a dentist like me, who has been doing orthodontics for over twenty years, to have to spend nearly $2000 for such a proprietary weekend course, the sole purpose of which is to teach me how to use their product!

Align Technologies utilizes a team of lawyers who try to put other aligner companies out of business for alleged patent violations. Aligners have been used for many years before Invisalign was invented. I don’t like corporate bully-boys who try to eliminate their competition this way.

Align Technologies is a publicly traded company which must answer to shareholders. Their business is to sell as many aligners as possible. I have seen Invisalign treatment plans that were overly aggressive and had little chance in success. Many inexperienced dentists get into trouble when they are “sold” such cases by Align Technologies.

Finally, as you can see in the “Lab Work Made in USA” section of my website, I support American labs and American jobs. Align Technologies has offshored its aligner fabrication to Mexico, and its clinical staff planning the cases to Costa Rica. The labs I use for aligners are 100% U.S. based.

Consumers are too easily influenced by advertising hype in printed media and television advertising. Just because something is highly advertised does not mean it is the only game in town, nor the best deal. Patients don’t know which brands of dental materials work best, nor which are the most cost effective. Leave that decision to the experts- the dentists who use them! Be assured that I will always be concerned for the health of your mouth AND of your pocketbook.

Parents of a 13-year-old child came in to have me review the appropriateness of their son’s orthodontic treatment. The father had wanted to bring their son to me for treatment originally, but the mother saw an advertisement for a chain of orthodontic clinics, promising substantial savings. The mother’s wish prevailed, and the child was 1 year into orthodontic treatment at this clinic with little progress.

I examined the boy. His was not a particularly difficult orthodontic case. I could have treated it in a little over a year and a half. But the corporate clinic had only fabricated some kind of removable expanders the child could not tolerate wearing regularly, and nothing much had been accomplished in the year of treatment.

It was hard to give the parents my conclusion. “I hate to tell you, but if I were to treat this case as it should have been when you started, it will cost you just under $4000 to complete. I guess your only consolation will be you didn’t spend much on the treatment that did not work.”

The mother looked visibly disturbed. She said, “Oh no. We have already paid $4000 for the treatment that has been done so far!” This woman had brought her son to a corporate orthodontic clinic thinking she would save money, and they totally wasted more money than what I would have charged to do the case correctly!

Not to brag, but I have been doing complete bracketed orthodontic cases since 1987. I know what I am doing. If patients cooperate, we get cases done quickly. I know a hard case when I see one, and have the sense to refer it to a select few orthodontists I know the ones who are super-competent.

Patients heed my recommendations about orthodontists very seldom. They listen to what I say. Then they go home and ask their friends and neighbors where to go, or they see some silly TV advertisement for a corporate orthodontic clinic, and go there. Many times, their case will never be completed correctly, if it is ever completed at all!

One of my adult patients asked me about straightening his teeth. I could see his case would be very difficult, with a high probability of needing jaw surgery to complete. I made a strong recommendation of one or two excellent orthodontists for such exacting treatment. The patient ignored me, and went to a corporate clinic. Fortunately, he later called telling me that they planned to do his initial exam and put the brackets on the same day. This was preposterous!

Any sane dentist would do an exam, take records, then do analyses and feasibility studies to work up such a difficult case as his. I spend at least 2 hours of analysis to work up an easy orthodontic case! Timing in orthodontics is often critical as well. Many cases, if started too early, will drag on for too long. These days, I often post photos of patients’ mouths online (omitting patient name, of course) and seek other orthodontists’ opinions about how the case should be treated. It would be ridiculous to put brackets and archwires on a patient the same day as the exam!

After being warned of the foolhardiness of proceeding, this patient changed his mind, took my advice, and saw a competent independent orthodontist. This is not always the outcome! Unfortunately, too often corporate orthodontists succeed in slapping on brackets and archwires to “lock in” the patient’s treatment at that clinic. Only afterwards do they try to figure out how to treat the case!

All good orthodontists forward a copy of their findings and treatment plan for a patient case to the treating general dentist. I virtually never receive these from corporate clinics, leading me to question whether there is even any logical treatment plan. I have received requests to extract teeth from corporate orthodontic clinics, then had to demand a rationale for the extrac­tions before I proceeded. I guess these orthodontists are under such pressures to perform, they allow no time for communication with the patient’s dentist!

Corporate ownership of orthodontic practices began in the early 1990s, as a result of the oversupply of orthodontists. Private equity investors thought they could use the same sales and business techniques to straighten teeth as they used dealing with auto repair and vacu­um cleaners. Health care is different, because all humans are all unique. No two orthodontic cases are exactly alike. There are even some orthodontic cases that should not be attempted. It is important that treating orthodontists not be subject to the will and profit incentive of non-dentist investors to treat the maximum number of cases without regard to appropriate timing or case difficulty or without sufficient diagnostic preparation.

Not every case I have seen from corporate orthodontic clinics has been done incompetently, but there are enough substandard case completions to be worrisome. One thing for sure: I don’t see any patient cost savings from corporate clinics, despite what is claimed in their glitzy advertisements.

As with every other service, I have personally found that the highest customer satisfaction is given by professionals who own their own business. It is true for general dentistry, and it is true for orthodontics as well. Please be skeptical about TV, radio, or print ads telling you to patronize any particular chain of orthodontic clinics. If you have any doubt before treatment, don’t hesitate to ask me about any particular orthodontic group you are thinking of using.

The other day a surgical patient needed a prescription filled for an antibiotic and pain reliever we had given her. She went to a big-box chain pharmacy to get it filled. Three hours later, a young voice called us saying the prescription could not be filled without an “attending physician’s” name. Missy repeatedly told the employee that ours was a dental office and all the necessary information was printed on the prescription. I was busy and could not take the call at the time. When we tried to call back, we were placed on hold for 30 minutes, and never could talk to anyone in the pharmacy.

The patient never was able to get the drugs she badly needed that evening. The store manager called us the next day to say that a young, inexperienced pharmacist was on duty that night, and did not know what she was doing.

I wish I could say that occurrences like that were a rarity, but such a fiasco happens nearly every week. Patients don’t realize that I can rarely speak to the pharmacists in big-box stores. They are just too busy and understaffed. I usually can only leave recorded messages on their voice mail systems. Eventually staff listens to most messages and fills the prescriptions, but a good part of the time they never get around to it. Then the patients often blame me, thinking I forgot to phone in the prescription.

Often times big-box stores don’t stock a variety of drugs, or enough of them. They often run out. Then they lie to patients and said I prescribed a rarely-used medication.

Patients always want to save money, but what is your time really worth? Is three hours of waiting worth saving $4?

The difference between dealing with big-box pharmacies and Mom & Pop drug stores is like night and day. I can call and talk to a pharmacist almost immediately. They give me suggestions for drugs that might be alternatives. They cut me slack and let me phone in scheduled drugs, and wait for the written prescription by mail. They work hard for patients’ business, and truly put patients’ interests first. Often the difference in drug costs between big-box and independent pharmacies is little if anything.

There aren’t many Mom & Pop pharmacies left, but they deserve your business. Chapman’s Drugstore in Hapeville has been in business for over 80 years and is only two blocks from my office. You seldom wait more than five minutes for a prescription! Christian’s Pharmacy in Forest Park is owned by one of my patients, and can even compound custom prescriptions for you. Moye’s Pharmacy gives speedy and efficient service to my patients in the McDonough area.

Corporate ownership has been nothing but bad for the dental profession, and I am not sure that it has been any less damaging to pharmacies. Please consider using your helpful independently owned local pharmacy next time you need a prescription filled. You will also support a valuable small business in your community!

Do you perhaps fit in one of the following groups?

*Dental plan that employer offers is a crumby PPO or DMO that excludes using good dentists not on the insurance list.

*You have a very healthy mouth, and virtually never need any treatment except regular cleanings, exams, and occasional x-rays, so dental coverage does not make economic sense.

*You are a self-employed individual without any form of dental coverage.

As expensive as dental care is, it really hurts to pay for it with after-tax income. Patients know that my #1 recommendation for funding dental care is through a FLEX benefit plan. It gives you complete freedom to pick dentists, and save all taxes on the money you put into it. You even avoid Social Security and Medicare taxes on salary you defer to the account!

Trouble is, as good as FLEX benefit plans are, not all employers offer them. And self-employed individuals cannot use them, unless they have a C-corporation.

What is a patient to do?

A good alternative is to use a Health Savings Account, which is much more efficient than buying dental insurance. Unlike when using a FLEX benefit plan, you will not avoid Social Security and Medicare taxes. But it will save some Federal and State income tax. How would you go about getting a Health Savings Account (HSA) open?

1. You must select a high-deductible, HSA-eligible medical coverage. More and more employers are offering this option. Typically the deductible must be at least $1200.
2. Fund the account to an EXCESS of what you need to pay for your medical deductible and copayments. For instance, if your typical out-of-pocket yearly medical expenses are $1500, contribute that PLUS however much per year you believe you will spend on family dental expenses. Ordinarily one would think to only contribute as much as a dental plan premium would cost monthly. But remember that any dental plan includes substantial out-of-pocket deductibles and copayments. So a starter would be to contribute 150% of the cost of premiums to a good dental plan.
3. The best place I have found to open a Health Savings Account is Delta Community Credit Union, because they have no fees and pay a good rate of interest. Perhaps some other credit unions have as good a deal.
4. You will get an HSA checkbook and/or debit card to pay your dentist with. He will love you, as you save him so many insurance hassles! And no insurance company will prevent you from having any dentistry you feel you want and need.

Individual dental benefit plans have always been a waste of money. We are finding that more employer-based dental plans are either poorly written, not a good deal, or both. Skipping the middlemen of dental plan underwriters can save you money and give you unlimited freedom of choice!

Feel free to e-mail me at KimHenryDMD@mindspring.com if you have any questions about implementing HSA dental funding.

Dentistry was a fairly happy profession when I grew up in the 1960s and most of the 1970s. The invention of the high-speed air rotor turbine in the late 1950s had made practice so much easier and more efficient. Bonding resins were just being introduced that would revolutionize anterior fillings. The new Medicaid program paid dentists virtually their normal fees for treating a whole new population of patients. Life was good for dentists, and getting better for dental patients.

Back then the average practice was owned by a single dentist, employing one hygienist, and having three treatment rooms or at most four. There were a few offices where pairs of dentists worked. Sometimes specialists like oral surgeons would pair up to own two office locations, mostly to trade off emergency call on weekends.

What insurance plans existed were based upon realistic fees of the area. If they were not, most all dentists would shun them and the plans would fail.

Although dental school was the most expensive of all professional educations, it did not demand the king’s ransom that it does now. School loans were much more limited back then. Often students would earn money during studies to pay for their educations. Qualified students took scholarships would pay the whole cost of dental school, plus living expenses, in return for four years of military service. The average student had a minimum of debt at graduation- nothing like the quarter million + dollars that is so common today. Many students, including me, graduated debt-free.

When a student graduated from dental school, he had the following options:

Join the dental corps in the military and gain more experience while earning a modest salary.

Take salaried government jobs in prisons, the Public Health Service, of the Indian Health Service. These jobs were few in number and often in remote locations.

Take out a loan and buy the practice of a retiring or deceased dentist.

Apprentice as a hired associate with a more experienced dentist, and buy practice equity in time with the goal of become a full partner or outright owner.

Borrow money and start a new practice, like a few of us high-risk takers did!

Those were about all the options for young dentists! It was rare that a dentist failed and bankrupted. Seldom was it caused by lack of patients. Most of the time is was due to poor money management or problems with addiction.

If the young dentist took options 3 or 5 above and worked hard and kept out of trouble, he could earn an adequate income to support a family. After practice debt was paid off, his income would increase to provide the niceties of life.

Going into practice back then was a lot cheaper. The average office was a little over 1000 square feet. There were no computer networks in those decades, so the bulk of the cash outlay went for dental chairs, control units, and x-ray machines in the treatment rooms, and a steam sterilizer for the instruments. The only major expense for the front office was an electric typewriter, as phones were often rented from the telephone company!

Federal Planning Went Wrong Back Then, Also!

Just about the time the benefits of fluoridated water were kicking in and reducing decay, the Federal Boys were convinced there was soon going to be a drastic shortage of dentists. Starting the in mid 1970s, they began blackmailing dental schools to increase dental class sizes every year. They did this by withholding money called “capitation funds” from dental schools unless they increased class sizes by a proscribed amount.

These extra dentists where dumped on the market in the late 1970s just in time for the economic slowdown. I remember in my senior year of 1979 talking to dentists in different areas of Georgia, hoping to find a spot to practice or a job offer. Instead of being encouraging, every one I talked to pleaded with me not to locate close to his practice, claiming there was already a shortage of patients. The two dental schools in Georgia were together pouring out about 170 new dentists a year, and flooding the state with dentists. Thank you, Federal Government, for your inaccurate predictions and subsequent meddling! It created an oversupply of young dentists looking for jobs, and that meant the wages they could command was much lower.

A few enterprising dentists saw the opportunity of hiring labor really cheap and began opening branch offices, principally in shopping centers. A factor making this easier was recent court rulings striking down all restrictions on professional advertising. One owner of a chain of offices told me he spent $30,000 a month in Yellow Pages advertising. This was in 1985!

I lasted all of six months in one of the Atlanta dental clinic chains that shall remain nameless. Patient care, although never top notch, was passable. There were not many liberties taken with billing. If a claim was sent to an insurance company for a filling, the filling most certainly had been done.

Caution against fraud and outright malpractice was exercised because the owners of the branch clinics were licensed dentists. They wanted to be at least marginally in compliance with state practice laws. The owner dentists would put their names on every office door, even if they only treated one patient there per month. If they were caught with hanky-panky in the offices, their own licenses could be suspended, or even permanently revoked. Yes, the owners encouraged overtreatment of patients to improve the bottom line, but they made sure the overtreatment was passable in quality. None of them wanted state board investigators on their back.

About this time insurance companies noted the oversupply of dentists, which gave them increased their negotiating power. They demanded 20% fee reductions in some of their plans. An even worse abomination was the Dental Maintenance Organization (DMO) contract, in which dentists took all the actuarial risk, and it was difficult to make any profit at all treating patients. However, despite their increasing numbers, few dentists would sign up for these jokes of benefit plans.

In 1991 Congress and the President passed a bill which seemed innocent enough, but in reality was one of the most intrusive and costly in US history. This was the Americans with Disability Act. Formerly, it was common for dentists to have offices as small as 900-1000 square feet. Under the new ADA, with its requirements for huge bathrooms and wide halls, this was impossible. New office space for a single dentist could rarely be smaller than 1200 square feet.

In essence, this increased the cost of opening new offices for dental graduates Not only that, but increased leased space meant increased monthly rents. A year or so before, the emergence of AIDs had increased practice costs quite a bit by virtue of much more extensive sterilization protocols. Starting and operating a new dental practice just got a great deal more expensive at a time when it was harder than ever to turn a profit.

Corporate Suits Take Notice of Dentistry

Dental employment was in a bit of a slump when I graduated in 1980, thanks to the Feds meddling with class size of dental schools. However, my friends in medical school had bright prospects and were readily employed for the most part.

Medical advances like organ transplants were being made routine. That plus the high inflation of the time was starting to make politicians leery of the increases in cost of health care. In 1980, most medical practices were still owned by physicians, although groups were beginning to appear, such as those that staffed hospital emergency rooms.

Medical expenses continued to climb in the 1990s, causing the Feds to worry about Medicare and Medicaid costs. The thinking of the time was that large clinical operations like HMOs could drive down the cost of health care. I am not sure of the enabling legislation, but corporations like Kaiser Permanente were allowed to employ physicians. It became more and more common for corporations to own medical treatment facilities, and employ physicians on a salaried or commissioned basis.

Technology continued to march on and increase medical costs, and government and insurers continued to keep medical fees stagnant. The profit potential of corporate medical clinics was limited, while the the liability costs were enormous in potential.

The decade 2000 to 2010 can realistically described as one of the decline of the American middle class. The Federal Reserve loosened monetary policy in preparation for the Y2K crisis that was supposed to appear but never did. This was one of the causes of the tech-telecom boom and bust, which made a lot of personal net worth disappear. The Fed loosened monetary policy again after the 9/11 terrorist attacks, causing the real estate boom and subsequent bust. Even more middle class assets were lost in the housing bust than in the tech bust. Meanwhile, the Chinese we emerging as fierce competitors in manufacturing. Many US jobs were disappearing, and US standard of living was declining as a result.

There was tremendous price pressure on the health professions. Medical had taken it on the chin before; now it was dentistry’s turn.

Corporate America had been watching with interest the chain clinic concept developed by entrepreneurial dentists, using the cheap labor of recent graduates. Now they wanted a piece of the action in a profession they saw as having less liability risk than medicine. The problem was that most states had laws on the books permitting only licensed dentists to own dental practices.

The first corporate target was orthodontic practice, as orthodontists were the dentists most in oversupply. It also seemed that orthodontics would be the easiest dentistry to mass-market. One orthodontic management company even tried to sponsor a residency program obligating graduates to be corporate employees for a time! Orthodontic management companies were the rage in the stock market for a while, until they crashed, and some bankrupted.

Dental practice statutes to protect patients were designed with dentist-owners in mind. The worst penalty possible was permanent revocation of state licensure. Only dentists were at risk. But that was logical, because until that time dentists were the only ones who could own offices.

To skirt around state practice law, corporate owners posed as “dental management companies.” The fiction was that the dentist treating patients in the facility was the actual owner. The dentist, in turn, employed the corporate entity to handle the business functions of the practice. This relationship was codified in long, tedious contracts. Facilities could be added to the corporate roster by:

“Affiliating” the practice of an existing dentist with the corporation. Often a combination of money and corporate stock was given as compensation. How the dentist could still be the owner of the practice after accepting a bulk payment from a corporation for rights to “manage” his practice is beyond my comprehension, but that was the official line.

Constructing turnkey facilities, then recruiting dentists to be the clinicians and “owners.” Often these dentists were right out of school with little clinical experience.

The fiction of an employee being an owner should be obvious to anyone having a functional cerebral cortex. True ownership can be determined by:

Who has the power to sell the practice and pocket the gains?

Does the power to replace or eliminate the management company exist?

Whose signature is necessary for check-writing?

In no cases that I am aware do the dentist(s) have these powers in corporate clinics.

Having tidy contractual relationships in place, unchallenged by any state except the valiant North Carolina Board of Dentistry, corporate America was ready to run amuck in the dental world.

Dental practice laws were written for good reason with protection of the patients as the goal. States wanted dentists to suffer consequences if patient welfare was not given priority. If a dentist performed fraudulently or incompetently, his license would be taken away. Not only would his income disappear, but the equity in his practice would decline fairly quickly.

Since corporate officers held no dental licenses, no such punishment could be meted out to them The license of the sham-owner dentist could be revoked, but a new sham-owner dentist could be quickly obtained by corporate officers.

As most sham-owner dentists were paid on a complicated commission structure, dental management companies were free to sign up for any dental benefit plans, no matter how low-paying. When they contract with DMOs, almost never do treating dentists receive a commission on the capitation payments. With such plans, the dentists are just told they have to work harder, or do more patient procedures, in order to make a commission. Many young dentists face crushing student debt burdens, and losing employment would be financial disaster for them. Knowing this, they are loathe to refuse revenue dictates (“goals”) by their corporate masters, whether patients need the treatment or not.

Although always denying it, corporate officers introduce severe distortions in the dentist-patient relationship. When something goes wrong, as a malpractice lawsuit or a patient death, the corporations usually get off free, as they can always point to the licensed dentist who performed the clinical treatment and is posed as the “owner.” It gets lost on juries that the dentists were coerced into unwise treatment by their “management company.”

One young dentist told me his corporate employer had videotape surveillance in all treatment rooms at all times! Talk about a violation of patient privacy! This dentist examined an elderly patient with a clotting disorder that needed an extraction, but refused to treat the patient until a medical consult could be arranged. The next day he was harangued by his non-dental employer for losing revenue by not doing the extraction! No doubt that this sort of pressure is behind many of the child deaths that occur when too much treatment is tried on small children at a single visit!

It is heartbreaking that intelligent young professionals are put in situations that force ethical compromise and substandard treatment. Yet fewer and fewer employment opportunities exist for young dentists outside the corporate world. Why is this?

The military services are downsizing their dental officer force, and using corporate contractors to treat troops instead of military dentists.

Hurt by low interest rates on their retirement assets, older dentists are practicing longer and not selling their practices. Even dentists who retired are coming back to practice because of need for more income.

Experienced dentists in their 50s do not have the excess patients that would provide sufficient income for a young dentist-associate. The older dentists don’t even have enough patients for their own sustenance, much less to spare for another dentist. Not a month passes that I don’t get a call from a recruiting agent trying to find a position for a newly graduated dentist.

Corporate money is a powerful tool with politicians. When North Carolina tried to pull the plug on corporate dental practice takeovers, the big guns were deployed to that state by affected corporate interests. Just as HMOs did in decades passed, dental corporations sing the siren song of cost containment and lower fees to the public. It plays better with politicians than lobbying for shareholder value.

The most unfortunate thing about the advent of corporate dentistry, after lowering the standard of care, is the lowering of public image of our profession. When inexperienced dentists are pressured into taking unwise risks and a fatality results, the public blames it on the dental profession. Next thing you know, voters want more intrusive government supervision of dentists. Seldom is it realized that the problem is not incompetence in our profession, but perverse incentives inherent in the corporate dental business model.

What can be done? Well, ownership of a dental practice could be codified so the corporate clowns could not masquerade as “management companies.” Corporations could be forced to divest from clinics unless it could be shown that dentists are the actual owners, by virtue of several tests of ownership. Contracts that clearly violate state practice law could be voided by courts. Losing offices one at a time would be devastating to corporate dental chains.

Private equity investors tend to be herd animals. I am old enough to remember the rush to shopping mall dentistry, which was supposed to be the wave of the future. It failed miserably. Then there was the rush to the nirvana of Orthodontic Management Companies, which largely disappeared. It could be that after being slammed with penalties for billing fraud, bait and switch, and other consumer hanky-panky, corporate dental clinics will be seen as places for the public to avoid. Already I have encountered a Facebook page dedicated to complaints against one dental chain, and a whole website dedicated to exposing the hijinx of just one location of another national dental chain!

Word spreads around quickly in the information age. I am hoping the truth will eventually get out about the corporate dental model. This essay, if widely read, may be one more nail in the corporate dentistry’s coffin!

A prospective patient came by one day to interview me. She was looking for a new dentist for her family. She and her husband were intelligent people and owned two successful businesses. This woman was doing her best to select a good dentist for her family- or so she thought.

The questions she asked centered on what expensive gadgets I had bought for my office. Did I have digital x-rays? Did I have a laser? How about one of those expensive CAD-CAM machines that makes crowns while patients wait?

Sorry to say, I am a conservative business owner who is leery of incurring debt to buy expensive and unproven equipment. I must have disappointed this woman, as she did not return. Doubtless she found a dentist with most of the expensive gadgets she thought were standard for good dental treatment.

It is unfortunate, but a lot of people think many expensive gadgets = quality dental care. This is in no small part due to manufacturers’ propaganda. In the high-overhead professions of both medicine and dentistry, it is a hard sell to get docs to buy expensive new equipment. Nobody wants to be an early adopter who spends $50,000 on an invention that doesn’t live up to its expectation.

So the trend is to first advertise any new expensive technology directly to patient populations. Without a professional background and access to scientific journals, it is easy for the average patient to be convinced that some new gadget is the greatest thing since sliced bread.

The next step is for manufacturers to post an online list of dentists who bought their product, so patients can view and patronize these practitioners. In this way, manufacturers seek to reward dentists who make a large purchase of their new equipment.

Am I against new technology? Absolutely not. My problem is that much of it does not work out to be practical or economical. Someone has to pay for this expensive stuff. Invariably it is the patients via higher fees. It is instructive to look through the “For Sale- Used” ads in my dental journals and see what is available. Invariably I encounter expensive items that were highly touted three to four years prior, but did not end up being a worthwhile investment. These gadgets sell used for pennies on the dollar.

Would digital x-rays save my patients radiation over my top-notch film and equipment? Not much, if any. Intraoral digital x-ray sensors are uncomfortable in the mouth and cannot be sterilized. The chief convenience is immediate reading by the dentist.

How about spending thousands of dollars for software to trace and measure parameters of skull x-rays for orthodontics? It would save me time, but considering the fact I analyze about eight such x-rays a year, would it make sense? Hand tracing and measurement take me a little time, but the result is just as good.

Would investing over $100,000 in a CAD-CAM machine to make crowns in the office do better than my lab technicians? Not from the examples I have seen. And the crowns still have to be custom-stained to look authentic. But again, it is convenient for the dentist not to have to schedule a second patient appointment for cementation.

Would a $40,000 laser work magic on my patient’s gums? Well, it is not true that patients don’t need anesthetic injections before using lasers. These machines cut very slowly, and stink when they do. The only convincing use I have seen for lasers is to cut gums around implants, where my electrosugery unit cannot be used. In dentistry at least, lasers seem like expensive toys.

By now I am sure you get the picture. With high enough patient volume, there are a few technologies that sometime make sense for a practice. These are few and far between. For every technology that proves itself in medical or dental practice, there might be nine that disappear because they do not live up to expectations.

In dental and medical practice, if you don’t get diagnosis and treatment planning right, no technological marvel in the world will make up for it. Technology is no substitute for experience in surgery. The main effect of technology is to increase doctor productivity. In general, the number of high-tech gadgets in an office is not a good indicator of quality of treatment you will receive.